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CHAPTER - 2

LITERATURE REVIEW

2.1 Introduction:

The World Health Organization (WHO) as “the state of complete physical, mental

and social wellbeing and not merely the absence of disease or infirmity” has defined

health care. Health care remains one of the most important human endeavors to

improve the quality of life. It also provides a comprehensive definition of a health

care system as one of that “…encompasses all the activities whose primary purpose is

to promote, restore or maintain health….and include(s) patients and their families,

health care workers and caregivers within organizations and in the community and the

health policy environment in which all health related activities occur.”

The main objective of any healthcare system is to facilitate the achievement of

optimal level of health to the community through the delivery of services of

appropriate quality and quantity. One another objective of health reform worldwide is

to hold healthcare accountable for its resource use and the way healthcare services are

delivered. This relates not only to the overall health of individuals and communities

but to the quality of the healthcare experience (Reinhardt, 1998)1.The structure of the

health care system in India is complex and includes various types of providers. These

providers practice in different systems of medicines and facilities. The providers and

facilities in India can be broadly classified by using three dimensions: ownership

styles (public, private not –for profit, private for-profit and private informal);systems

of medicines (allopathic, homeopathic and traditional); and types of facilities

(hospitals, dispensaries and clinics). These dimensions are interdependent and

overlapping (Bhat,1993)2.

Using the ownership criterion, the health care system can be divides into four board

sectors:

• The public sector, including government-run hospitals, dispensaries, clinics,

primary health care centers and sub centers and paramedics.

1Reinhardt U. (1998), ‘Quality in consumer-driven health systems’ ; .International journal of Quality in

Health Care 10(5): 85-94. 2Bhat , R.(1993). The private/public mix in health care in India. Health Policy and planning,8(1),43-56.

45

• The private not- for profit sector, including voluntary health programs

charitable institutions,missions, churches and trusts

• The organized private for profit sectors, including general practitioners

(having at least a bachelor’s degree or equivalents in medicine),private

hospitals and dispensaries (popularly known as nursing homes), registered

medical practitioners and other licensed practitioners.

• The private informal sector, including practitioners without formal

qualifications (such as faith healers, herbalists, tantriks ,hakims, and vaidyas).

Increasing the availability, accessibility and awareness about the services and

technological advances for the management of health problems, raising

expectations of the people, and the ever-increasing cost of healthcare are some of

the challenges that the healthcare systems have to cope up with. The development

of the private health care sector is due to a number of interacting factors. These

factors include the growth of household incomes, the inadequacies of the public

health sector, and the effects of various government policies on the operation of

different health care markets (Alejandro Herrin, 1997)3. The private health sector

plays an important role in India’s health care delivery system. Through a wide

network of health care facilities, this sector caters to the needs of both urban and

rural populations and has expanded widely to meet increasing demands.

This increasing importance has raised requirements for health care marketing. The

American Marketing Association offers, “Marketing is an organizational function and

a set of processes for creating, communicating and delivering value to customers and

for managing customer relationship in ways that benefits the organization and its

stake holders (Kotler Philip, Sholawitz Joel et al, 2008)4.

The level of competition has increased in health care sector. Patients’ satisfaction is

emphasized highly in competitive market. Patient satisfaction with medical care is a

multidimensional concept, with dimension that corresponds to the major

characteristics of providers and services. Patient satisfaction with health care services

3 Alejandro Herrin(1997) “ private Health sector performance and Regulation in the Philippines”,in

edited book titled, ‘Private Health sector growth in Asia Issues and implication’ by William Newboarner, publication John Wiley & Sons, Ltd.pp.157.

4KotlerPhilip,Sholawitz Joel and Steven J.Robort,2008 titled “Strategic organasations Building a customer driven Health system published by Jobssey-Bass, A Wiley Imprint,p.5

46

is considered to be of paramount importance with respect to quality improvement

programs from the patients’ perspective, total quality management, and the expected

outcome of care.Within the health care industry, patient satisfaction has emerged as

an important component and measure of the quality of care. Consumer satisfaction

appears to be a major device in order to take critical decisions in the health care

services (Gilbert, Lumpkin &Dant, 1992) 5. Therefore, service providers, as a matter

of fact, take the satisfaction of customers into account as a main goal of the strategies

of their firms (Zeithaml&Bitner, 2000)6. Patient satisfaction plays an important role

in continuity of service utilization. Satisfied patients are more likely to adhere to

doctors’ recommendations and medical suggestions. Besides, dissatisfied patients do

not use that health care services. The fast developing health care industry, hospitals

like their counterparts, have to deal with several service product characteristics such

as intangibility, heterogeneity and perishability more over high risk exist for the

private hospitals offering their services in a competitive environment dealing with

human health, which involves sensitive decision.

2.2 Patient Satisfaction:

Notionally, consumer surveys or patient feedbacks can be used for assessment of

individual clinician, trust, organisation or region and analysed to compare it with

its/their own past performances, similar surveys at different hospitals, national

average or benchmarked performances. These can help in improving insight and help

to learn from own or others experiences. Likewise these can be useful tool for

policymakers, researchers, and for managers to know more about their services. The

outcomes of the consumer surveys can be used by the governing or regulatory bodies

like Health Care Commission to measure performance.

RituNarang (2010)7applied 20-item scale and distributed to 500 users of health

care centers comprising a tertiary health center, a state medical university and

two missionary hospitals in Lucknow, India. The scale was found to be reliable

to a great extent with an overall Cronbach alpha value of 0.74. “Health personnel

5Gilbert, F. W., Lumpkin, J. R., &Dant, R. P. (1992). Adaptation and customer expectation of health

care options. Journal of Health Care Marketing, 12(3), 46–55. 6Zeithaml, V. A., &Bitner, M. J. (2000).Services marketing. New York: McGraw-Hill. 7RituNarang (2010),Measuring perceived quality of health care services in India;International Journal

of Health Care Quality Assurance Vol. 23 No. 2, 2010 pp. 171-186.

47

and practices” and “health care delivery” were found to be statistically

significant in affecting the perception. Respondents were relatively less positive

on items related to “access to services” and “adequacy of doctors for women”.

The tertiary health center was rated poorer than the medical university and

missionary hospitals. Policy makers needed to consider the requirements and

opinions of patients to effect substantial change and significant improvement in

the quality of their health care services for better and increased utilization of

their services. This tool may be applied for qualitative assessment of the services

of health care programmes as well as health care centers of India.

2.2.1 Consumer survey as an effective tool to improve:

Patient satisfaction had been extensively studied and considerable effort had gone

into developing survey instruments to measure it. However, most reviews have

been critical of its use, since there was rarely any theoretical or conceptual

development of the patient satisfaction concept. The construct had little

standardization, low reliability and uncertain validity. It continued to be used

interchangeably with, and as a proxy for, perceived service quality, which was a

conceptually different and superior construct.

Anjali Patwardhan (2009)8 tried to find effectiveness of consumer surveys as

valuable to implement service improvement tool in health services. In the recent

climate of consumerism and consumer focused care, health and social care needs

to be more responsive than ever before. The consumer needs and preferences can

be elicited by customaries and specific consumer surveys. Most researchers now

go for consumer experience surveys rather than just satisfaction surveys because

of their clear superiority in identifying the specific opportunities for improvement

and the ease of translating the outcome information from these surveys in to the

strategic planning for improvement.

8Anjali Patwardhan (2009), A retrospective on access to health care; International Journal of Health

Care Quality Assurance Vol. 20 No. 6, 2007 pp. 494-505 Emerald Group Publishing Limited .

48

2.2.2 Factors affecting Patients’ satisfaction:

Healthcare is a high involvement service as it concerns the person’s health and well

being. Customer satisfaction and loyalty are such a strong and “value-laden” notion

that it is usually applied only to family and friends. Patient satisfaction has always and

will be a fundamental requirement for clinical and financial success of any

organization providing health care, regardless of specialty. Nesreen A.

Alaloola(2008)9conducted research survey to find Patient satisfaction in a Riyadh

Tertiary Care Centre. Patients were significantly satisfied with treatment room

cleanliness (90 percent). They were significantly dissatisfied, on the other hand, with

the interpreter’s failure to introduce him/her self (57.6 percent). They were

significantly satisfied with the time he/she spent with doctors (90.1 percent) and the

way they were treated with respect and dignity (74.8 percent). Also, patients were

significantly satisfied with emergency care staff allowing relatives to accompany

patients undergoing treatment (60.9 percent). Discharge medication and related

information was well rated (67.1 percent) and post discharge care information

generally (56.4 percent). There was significant satisfaction with pharmacists treating

patients with respect and dignity (79.4 percent), explaining how to use their

medications (78.1 percent) and that all prescribed medications were available from the

pharmacy (60.7 percent). Finally, patients were significantly dissatisfied with

emergency care staff information (52.7 percent), while they were significantly

satisfied with the military police being available to provide directions if needed (77.6

percent), staff respecting the Saudi culture (82.8 percent) and communicating ease

(82.1 percent).

Kenneth E. Covinsky, and Gary E. Rosenthal, et al. (1999)10interviewed patients at

admission and discharge to obtain two measures of health status. At discharge, they

also administered a 5-item patient satisfaction questionnaire. They assessed the

relation between changes in health status and patient satisfaction. In two sets of

analyses, that controlled for either admission or discharge health status. They found

9Nesreen A. Alaloola(2008), Patient satisfaction in a Riyadh Tertiary Care Centre; International Journal

of Health Care Quality Assurance Vol. 21 No. 7, 2008 pp. 630-637. 10Kenneth E. Covinsky, and Gary E. Rosenthal, et al. (1999), The Relation Between Health Status

Changes and Patient Satisfaction in Older Hospitalized Medical Patients; Health Status Changes and Patient Satisfaction Volume 13. April 199;p.p.224-229.

49

that Patients with similar discharge health status had similar satisfaction regardless of

whether that discharge health status represents stable health, improvement, or a

decline in health status. The previously described positive association between patient

satisfaction and health status more likely represents a tendency of healthier patients to

report greater satisfaction with health care. They suggested that changes in health

status and patient satisfaction were measuring different domains of hospital outcomes

and quality.

Accurate diagnosis and treatment are no longer enough; patients need performance in

all services they receive. Performance makes consumers return to the same provider

and spread more favorable “word of mouth” recommendation. Moreover, human

beings live as members of groups that share common values and norms and interact

according to specific rules and laws, which shape several human reactions.

Amira Elleuch (2008)11tried to measure patient satisfaction in Japan. Japanese healthcare

service quality was evaluated using its process characteristics (patient-provider

interaction) and physical attributes (settings and appearance). Process quality attributes

found experience patient satisfaction. Satisfaction in turn predicts patient intentional

behavior (to return and to recommend). Japanese society cultural specificity seems to be

an interesting background to understand Japanese evaluation when patients assess health

service quality. In accordance with their culture’s specificities, Japanese outpatients focus

on delivery processes – characterized by service speed, quality of interaction with staff

and the setting’s appearance when assessing health care service quality. In contrast with

individualist cultures (USA and Europe), Japanese hate specific attention and

individualized staff behaviors considering that physicians or nurses should deal equally

with all the patients.

Patinets’ satisfaction largely depends on how nicely services are being delivered.

Nurses are playing very important role and nurses are the largest groups among health

care professionals and are legally liable and morally responsible for their care, thus

their perspective on quality of nursing care is important. Mansoureh Z. Tafreshi,

11AmiraElleuch (2008) Patient satisfaction in Japan, International Journal of Health Care Quality

Assurance Vol. 21 No. 7, 2008 pp. 692-705.

50

Mehrnoosh Pazargadi and Zhila Abed Saeedi (2007)12have made an attempt to

find similarities and differences between nursing experts’ and clinical nurses’

perspectives on quality and patient satisfaction. Findings revealed that in nurses’

perspectives on quality definition two important aspects have been mostly considered:

“standard of care” and “patient satisfaction”. Moreover participant groups have

emphasized the benefits of collaborative work in health care (teamwork). Further in

this study, organizational and socio-cultural roles in delivering quality nursing care

have been mentioned such as staffing, budget, leadership, and social perspectives

about nursing as a highly educated profession.

Koichiro Otani& Fort Wayne (2009)13conducted the study to find out what

influenced adult patients to rate their overall experience as "excellent." The data

collected from one major academic hospital and four community hospitals. After

conducting a multiple logistic regression analysis, certain attributes were shown to be

more likely than others to influence patients to rate their experiences as excellent. The

study revealed that staff care was the most influential attribute, followed by nursing

care. These two attributes were distinctively stronger drivers of overall satisfaction

than the other attributes studied (i.e., physician care, admission process, room, and

food). Staff care and nursing care were found under the control of healthcare

managers.

Hospital food services are an important component in the healthcare management of

patients. The provision of patient meals should be regarded as a component of

hospital treatment as the nutrients provided can promote recovery, especially if

patients have no other options for getting food while hospitalized. Measuring patient

satisfaction toward hospital food services is one tool used in research to improve food

quality and catering services (Capra et al., 2005)14. Rosita Jamaluddin, Nurul

12Mansoureh Z. Tafreshi, MehrnooshPazargadi and Zhila Abed Saeedi (2007)Nurses’ perspectives on

quality of nursing care: a qualitative study in Iran,International Journal of Health CareQualityAssuranceVol. 20 No. 4, 2007pp. 320-328q

13KoichiroOtani& Fort Wayne (2009), Patient Satisfaction: Focusing on "Excellent"; Journal Of Healthcare Management 54:2 MARCH/APRIL 2009.

14Capra, S., Wright, O., Sardie, M., Bauer, J. and Askew, D. (2005), “The acute foodservice patient satisfaction questionnaire: the development of a valid and reliable tool to measure patient satisfaction with acute care hospital foodservices”, Foodservice Research International, Vol. 16, pp. 1-14.

51

Aqmaliza AbdManan( 2010)15found the majority of the patients were satisfied the

food service in Malaysia. Energy (kcal) and protein intakes from hospital food were

higher than that of outside food. However, most patients did not obtain their full

energy and protein requirements from the hospital food provided.

Satisfying patients' needs is found the first step toward having loyal patients, so

hospitals that strive to ensure their patients were completely satisfied and more likely

to prosper. Nesreen A. Alaloola(2008)16conducted research survey to find Patient

satisfaction in a Riyadh Tertiary Care Centre. There was a significant satisfaction with

room comfort, room temperature, room call button system, room cleanliness and

respectful staff. Patients were significantly dissatisfied with phlebotomists not

introducing themselves, not explaining procedures and physicians not introducing

themselves.

Satisfaction determinants range from structurally based ones such as the type of health

care delivery system, to physician characteristics, including interactional style and the

physician’s age. Patients are difficult to satisfy, inconsolable and personally

challenging, no matter how comprehensive, efficient and expert neither care, nor how

polished the physician’s interpersonal skills. Patient satisfaction has been widely

studied. Brian A. Costello, Thomas G. McLeod and G. Richard Locke III

(2008)17conducted a research survey to find Pessimism and hostility scores as

predictors of patient satisfaction ratings by medical out-patients patients’ satisfaction.

Among the hostile patients, 57 percent rated their overall care by physicians as

excellent, while 66 percent of the least hostile patients rated it as excellent.

Dennish J Scotti and Joel Harmon(2009)18assessed the importance of customer-

contact intensity at the service encounter level as a determinant of service quality

assessments. It showed that performance-driven human resources practices play an 15Rosita Jamaluddin, NurulAqmalizaAbdManan and AinaMardiahBasri, Patients’ satisfaction with the

bulk trolley system in a government hospital in Malaysia, Leadership in Health Services Vol. 23 No. 3, 2010 pp. 260-268.

16Nesreen A. Alaloola (2008), ‘Patient satisfaction in a Riyadh Tertiary Care Centre’; International Journal of Health Care Quality Assurance Vol. 21 No. 7, 2008 pp. 630-637.

17Brian A. Costello, Thomas G. McLeod and G. Richard Locke III (2008), Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients; International Journal of Health Care Quality Assurance Vol. 21 No. 1, 2008 pp. 39-49.

18Dennish J Scotti and Joel Harmon(2009), Links Among High-Performance Work Environment, Service Quality, and Customer Satisfaction: An Extension to the Healthcare Sector; Journal OF Healthcare Management 52:2 MARCH/APRIL 2007.

52

important role as determinants of employee customer orientation and service

capability in both high-contact (outpatient healthcare) and low-contact (benefits claim

processing) human service contexts. However, there existed significant differences

across service delivery settings in the customer orientation and the similarity between

employee and customer perceptions of service quality, depending on the intensity of

customer contact. In both contexts, it was found that managerial attention to high-

performance work systems and customer-orientation has the potential to

favorablyimpact perceptions of service quality, amplify consumer satisfaction, and

enhance operational efficiency.

Michael Schroeter&IgorSavitsky (2010)19tried to investigate the implementation of

a novel organizational structure in a specialized hospital department. The key issue

was to optimize the efficiency of the process “hospital treatment” in a patient-oriented

approach. A new organizational concept, i.e. the Cologne Consultant Concept (CCC),

was developed by and implemented at the Department of Neurology, Cologne

University Hospital in August 2007. The outcome of this reorganization was

evaluated via a number of critical performance parameters (effects on daily routines

and performance data, feedback from quality control and house officers).

Furthermore, the strengths and weaknesses of this novel system were compared to the

traditional ward-based system in Germany, the Anglo-American consultant model and

care provided by sub-specialized teams. The reorganization of the healthcare services

by the CCC provided flexible medical care for inpatients. The independent

assignment of patients to a ward, and a team of physicians offered incentives for case-

oriented and efficient medical treatment. Furthermore, beneficial effects on the

department’s overall performance compared to the traditional ward-based system

were observed. The CCC constituted a valuable new organizational structure that can

provide medical care in any specialized hospital department.

In any hospital emergency department is playing very important role. Emergency

departments (EDs) are an important hub in our health care system. They handle acute

illnesses and injuries, are an important gateway to admission to hospitals and also

19 Michael Schroeter&IgorSavitsky (2010); A novel organizational structure to provide medical care in

specialized hospital departments:The Cologne Consultant Concept, Leadership in Health Services Vol. 23 No. 4, 2010 pp. 320-333 q

53

provide medical care when a patient’s regular physician is unavailable. Keith A.

Willoughby& Benjamin T.B. Chan (2010)20made study to determine the wait time

and service time for various emergency department (ED) patient care processes and to

apply the science of plan-do-study-act (PDSA) cycles to improve patient flow. The

paper used direct observation to collect patient- flow- data on 1,728 patients at

multiple ED sites in Saskatchewan, Canada. It calculated wait times and services

associated with important care processes and then tested, measured and implemented

ideas to reduce wait time. The study discovered on an average, patients spend nearly

five hours in the ED with about one-half of the visit devoted to waiting for the next

required service to take place. Waiting for an inpatient bed, specialist consultation or

physician reassessment comprised relatively long wait times. Through the use of

visual reminders and standard process worksheets, quality improvement teams were

able to achieve large reductions in physician reassessment waiting time. These

improvements required minimal materials cost and no additional staff.

Marie Boltz, Elizabeth Capezuti and Nina Shabbat (2010)21tried to define the core

components of a system-wide, acute care program designed to meet the needs of older

adults. Concept mapping methodology (multidimensional scaling and cluster analysis)

was used to obtain data describing the core components of a geriatric acute care

model. The input of 306 “stakeholders” (clinicians, administrators, consumers,

educators, and researchers) was obtained through a World Wide Web interface,

supplemented with consumer interviews. The findings yielded eight clusters

describing components of a geriatric acute care program: guiding principles,

leadership, organizational structures, physical environment, patient- and family-

centered approaches, aging-sensitive practices, geriatric staff competence, and

interdisciplinary resources and processes.

20Keith A. Willoughby& Benjamin T.B. Chan (2010), Achieving wait time reduction in the emergency

department; Leadership in Health Services Vol. 23 No. 4, 2010 pp. 304-319. 21Marie Boltz, Elizabeth Capezuti and Nina Shabbat (2010); Building a framework for a geriatric acute

care model; Leadership in Health Services Vol. 23 No. 4, 2010 pp. 334-360.

54

Johan Hellings, Ward Schrooten and NiekKlazinga (2007)22measured patient

safety culture in five Belgian general hospitals. Safety culture played an important

role in the approach towards greater patient safety in hospitals. The dimensional

positive scores were found to be low to average in all the hospitals. The lowest scores

were “hospital management support for patient safety”, “non-punitive response to

error”, “hospital transfers and transitions”, “staffing”, and “teamwork across hospital

units”. The dimension “teamwork within hospital units” generated the highest score.

Although the same dimensions were considered problematic in the different hospitals,

important variations between the five hospitals were observed.

SeetharamanHariharan, Prasanta Kumar Dey (2010)23introduced a quality

management framework by combining cause and effect diagram and logical

framework. An intensive care unit was identified for the study. They found that

patients improved infrastructure, state-of-the-art equipment, well maintained facilities,

IT-based communication, motivated doctors, nurses and support staff, improved

patient care and improved drug availability were considered the main project outputs

for improving performance. The proposed framework was used as a continuous

quality improvement tool, providing a planning, implementing, monitoring and

evaluating framework for the quality improvement measures on a sustainable basis.

Peter Hensen, Meinhard Schiller, Dieter Metze and Thomas Luger

(2008)24evaluated the perception of hospital services by referring physicians and

clinicians for quality improvement. Referring physicians in private practice and

hospital clinicians at a large dermatology academic department providing inpatient

and outpatient services at secondary and tertiary care levels were surveyed to

determine their perceptions of service quality. A comparative questionnaire survey

was established to identify improvement areas and factors that drove referral rates

using descriptive and inferential statistics. Referring physicians’ (n ¼ 53) and

22Johan Hellings, Ward Schrooten and NiekKlazinga (2007), Challenging patient safety culture: survey

results; International Journal of Health Care Quality Assurance Vol. 20 No. 7, 2007 pp. 620-632.

23Seetharaman Hariharan, Prasanta Kumar Dey (2010), A comprehensive approach to quality management of intensive care services, International Journal of Health Care Quality Assurance Vol. 23 No. 3, 2010 pp. 287-300.

24Peter Hensen, Meinhard Schiller, Dieter Metze and Thomas Luger (2008), Evaluating hospital service quality from a physician viewpoint, International Journal of Health Care Quality Assurance Vol. 21 No. 1, 2008 pp. 75-86.

55

clinicians’ (n ¼ 22) survey results concordantly revealed that timely and

significant information about hospital stay as well as accessibility to hospital staff

were major points for improvement. Significant differences between both samples

were found with respect to inpatient services and patient commendation.

Clinicians tended to rate their services and offerings higher than referring

physicians (p ¼ 0:019). Geographic range was correlated with the frequency of

patient commendation (p ¼ 0:005) and the perception of friendliness (p ¼ 0:039).

The number of referred patients was correlated with medical reports’

informational value (p ¼ 0:042).

Nurses heavily influence patient care quality and safety. Ari Mawachofi and

Stephen L. Walston (2011)25attempted to find factors affecting nurses’

perceptions of patient safety. This paper aimed to examine socioeconomic and

organizational/system factors affecting patient safety and quality perceptions.

They found that improved patient safety and the likelihood that nurses use their

own facility include: fewer visible errors; ability to communicate suggestions;

information technology support and training; and a confidential error reporting

system. Furthermore, nursing in these hospitals was dominated by foreign

nationals. The high positive patient safety perceptions may be influenced by either

individual or peer biases.

Abdul MajeedAlhashem, HabibAlquraini and Rafiqul I. Chowdhury(2011)26

measured the quality of health care services and patient satisfaction as one of the

most important indicators. The study aimed to identify factors affecting patient’s

satisfaction at primary health care clinics. The data was collected during January 2007

and May 2007 through a randomly-distributed questionnaire. The questionnaires were

distributed in primary healthcare clinics that represent all heath care regions in

Kuwait. A total of 426 completed questionnaires, out of 500, were returned resulting

in a response rate of 85.2 percent. The majority (87 percent) of the patients responded

that the time for communication between physician and patient was not enough. 25Ari Mawachofi and Stephen L. Walston (2011), Factors affecting nurses’ perceptions of patient

safety; International Journal of Health Care Quality Assurance Vol. 24 No. 4, 2011 pp. 274-283.

26Abdul MajeedAlhashem, HabibAlquraini and Rafiqul I. Chowdhury(2011), Factors influencing patient satisfaction in primary healthcare clinics in Kuwait; International Journal of Health Care Quality Assurance Vol. 24 No. 3, 2011 pp. 249-262.

56

Seventy-nine-percent of the surveyed patients said they would go to the emergency

room of the hospital in future if needed instead of going to the primary care clinic.

Regarding the quality of the communication relationship between physician and

patients most of the patients responded negatively.

Masood A. Badri and SamaaAttia (2009)27discussed goodness-of-fit statistics

supported the healthcare quality-patient status-satisfaction model. Their results sent an

important message to hospital managers, confirming that healthcare quality in terms

of reliability (including competence, knowledge and trust), professionalism and

courtesy, empathy and tangibles were crucial when it comes to evaluating services.

Complaints about the provision of health care have increased as consumers’

expectations of care and awareness of their rights have grown (Anderson et al., 2001;

Chavan et al., 2007)28 and are frequently considered to be unwelcome. Health

professionals and/or health care organisations may react to complaints with fear and

defensiveness (Anderson et al., 2001)29. Julianne Parry and UdulHewage

(2009)30conducted a research survey in Australia to know the complaints resolution.

And found that Three main themes. These themes were labelled: “communication”,

“wait times” and “clinical”. The complaints were readily identified as falling into

three main themes. These were: complaints about communication, complaints about

wait times and complaints labelled as “clinical” as they related to concerns about the

care provided to the patient or their relative.

Satisfaction with quality parameters like service proximity, doctor availability,

waiting time, etc., can be used as a performance goal to evaluate healthcare

organisations. Citizen satisfaction is the most important parameter. Sandip Anand

27Masood A. Badri and SamaaAttia (2009), Testing not-so-obvious models of healthcare quality;

International Journal of Health Care Quality Assurance Vol. 21 No. 2, 2008 pp. 159-174 q 28Anderson, K., Allan, D. and Finucane, P. (2001), “A 30-month study of patient complaints at a

major”, Australian hospital Journal of Quality Clinical Practice, Vol. 21, pp. 109-11. 29 Ibid 8 30 Julianne Parry and UdulHewage (2009), Investigating complaints to improve practice and develop

policy; International Journal of Health Care Quality Assurance Vol. 22 No. 7, 2009 pp. 663-669.

57

(2010)31carried out the follow-up survey in Tamil Nadu, Maharashtra, Bihar and

Jharkhand. Dimensions include: service proximity, doctor availability, waiting time,

medicines, facility cleanliness, dignified treatment, privacy, service affordability and

treatment effectiveness. Findings indicated that doctor availability, waiting time,

cleanliness, privacy and affordability at private health facilities enhance the

probability that a health facility will be used for any reproductive health purpose.

Their findings indicated that doctor availability, waiting time, cleanliness, privacy and

affordability enhance private reproductive health service use at the combined four

state level. At the combined states, medicine availability and treatment effectiveness

at public health facilities enhances use. It appeared from their findings that service

quality norms were not properly established in any Indian public or private systems.

Therefore, to improve health service quality, hospitals need to emphasise holistic care.

At the combined states level, medicine availability and treatment effectiveness at

public health facilities enhances service use.

2.2.3. Patients’ loyalty:

Patient satisfaction affects propensity to return, i.e. loyalty. Based on the existing

evidence that the patient satisfaction was found an unpredictable construct, a focus

entirely on perceived service quality, as the definitive construct, was justified; and

given the extremely high intensity nature of the service. Satisfaction’s impact on

hospital choice is particularly important. Research shows a link between patient

satisfaction and healthcare quality.

Reichheld developed a model for connecting customer satisfaction to quality,

improvement, customer loyalty and retention. He suggested that a single question

can explain 90 per cent of customer satisfaction variance (Reichheld, 2006)32.

This question, which he terms “the ultimate question”, is: “On a scale from 0-10,

how likely are you to recommend a product or service to a colleague, family

member, or friend?” Thus, the most natural thing for a customer to do if he or she

31SandipAnand( 2010), Quality differentials and reproductive health service utilisation determinants in

India; International Journal of Health Care Quality Assurance Vol. 23 No. 8, 2010 pp. 718-729.

32Reichheld, F. (2006), The Ultimate Question, Harvard Business School Press, Boston.

58

loves doing business with a particular provider is recommend that provider to

someone he/she cares about (Reichheld, 2006)33.

Patient satisfaction actually predicts provider choice suggests a pathway through

which individuals naturally gravitate toward higher-quality care, despite the

difficulties inherent in evaluating service quality. Satisfied patients are also more

likely to adhere to recommended treatment.Daniel P. Kessler and Deirdre Mylod

(2011)34aimed to investigate the same. The results showed a statistically

significant link between patient satisfaction and loyalty. This result persists, even

holding constant hospital characteristics and process-based quality measures likely

to be highly salient to satisfaction. Although this result was statistically

significant, it was relatively small in magnitude.

Helena Vinagre and Jose´ Neves( 2010)35 have found the more a patient feels

interested and joyful, the better his appreciation of justice in doctor-patient

relationship and the healthcare centre processes.

Delivering best quality of services is important at the same time this should have been

done more effectively and efficiently. J. Dummer (2007)36found that the task of

defining the way in which health care could be most efficiently and effectively

delivered was the concern of all health care staff. Management also had the

responsibility of ensuring the consistency and coherence of the many different

activities that contributed to the aim of good health care.

Amy Lodge, David Bamford (2007)37had tried to measure health service

improvement through diagnostic waiting list management. The results were

recognised as being beneficial to all parties, especially the patients. Staff recognised

the need for change; the process transformation was actually welcomed. Patient

33 MA. Reichheld, F. and Sassar, W. (1990), “Zero defection quality comes to service”, Harvard

Business Review, Vol. 86 No. 5, pp. 9-17. 34Daniel P. Kessler and Deirdre Mylod( 2011), Does patient satisfaction affect patient loyalty?;

International Journal of Health Care Quality Assurance Vol. 24 No. 4, 2011 pp. 266-273. 35Helena Vinagre and Jose´ Neves( 2010), Emotional predictors of consumer’s satisfaction with

healthcare public services; International Journal of Health Care Quality Assurance Vol. 23 No. 2, 2010 pp. 209-227.

36 J. Dummer (2007),Health care performance and accountability; International Journal of Health Care Quality Assurance Vol. 20 No. 1, 2007 pp. 34-39.

37Amy Lodge, David Bamford ;(2007), Health service improvement through diagnostic waiting list management; Leadership in Health Services Vol. 20 No. 4, 2007 pp. 254-265.

59

waiting times reduced from 26 to 13 weeks. Fast-track“query cancer” service for out-

patients now within ten days; the majority of in-patients receive imaging within 72

hours. Ultimately, patients were diagnosed faster and treatment commences earlier.

A high-involvement approach to the work environment of healthcare employees may

lead to exceptional service quality, satisfied patients, and ultimately to loyal

customers. Dennis J. Scotti, Alfred E. Driscoll (2007)38said healthcare managers

must deliver high-quality patient services that generate highly satisfied and loyal

customers. In this article, researchers had investigated how specifically, the chain of

events through which high-performance work systems (HPWS) and customer

orientation influence employee and customer perceptions of service quality and

patient satisfaction. They presented a conceptual model for linking work environment

to customer satisfaction and test this model using structural equations modelling. The

results suggested that (1) HPWS was linked to employee perceptions of their ability to

deliver high-quality customer service, both directly and through their perceptions of

customer orientation; (2) employee perceptions of customer service were linked to

customer perceptions of high-quality service; and (3) perceived service quality was

linked with customer satisfaction and loyalty.

Boshaff and Gray (2004)39 conducted their research on patients of private health

organizations in South Africa and found that the service quality dimensions of

nursing staff viz. empathy, assurance and tangibles have positive impact on the

loyalty of patients.

38Dennis J. Scotti, Alfred E. Driscoll (2007), Links Among High-Performance Work Environment,

Service Quality, And Customer Satisfaction: An Extension To The Healthcare Sector; Journal OF HEALTHCARE MANAGEMENT 52:2 MARCH/APRIL 2007.

39Boshoff C, Gray B (2004). The relationship between service quality, customer satisfaction and buying intentions in the private hospital industry. South Afr. J. Bus. Manage., 35(4): 27-37.

60

2.3. Hospital Management:

Organizations need to improve what they are currently doing as well as changing

operations to what they should be doing, and after measuring the outcomes they

should search for improvements on other new activities. Every improvement requires

a change, either in small scale or in large scale, and every change requires an act of

creation (Sommers, 1998)40.

2.3.1. Quality control techniques:

Johan Thor andBoHerrlin (2010)41conducted a research study to measure

effectiveness of quality improvement programmes. It was found overall, 58 percent of

the program’s projects (39/67) demonstrated success. A greater proportion of projects

led by female doctors demonstrated success (91 percent, n ¼ 11) than projects led by

male doctors (51 percent, n ¼ 55). Facilitators at the hospital continuously adapted the

improvement methods to the local context. A lack of dedicated time for improvement

efforts was the participants’ biggest difficulty. The dominant benefits included an

increased ability to see the “bigger picture” and the improvements achieved for

patients and employees.

Six sigma is widely used quality control technique in manufacturing and service

organization. It offers a way of measuring the performance capability of existing

systems or processes. The higher the sigma level, the higher the performance of

the healthcare system.

Patient satisfaction, physician satisfaction, reduced overtime, reduced patient wait

times, increased revenues and an enhanced quality of life for healthcare personnel are

some of the outcomes of moving to the higher sigma level. The goal is to move from

the current state to a future, more productive state. By means of adopting six-sigma

philosophy, the healthcare organization can achieve a cultural change. This will lead in

realizing sustainable bottom-line results in the hospital. Mehmet TolgaTaner and

BulentSezen (2007)42made an attempt to give over wise of six sigma applications in

healthcare industry at Turkey. Delays measurement and medical errors and variability 40Sommers, P.A. (1998), Medical Group Management in Turbulent Times, The Haworth Press, New

York, NY, p. 26. 41Johan Hellings ,Ward Schrooten, NiekKlazinga Arthur Vleugels, Challenging patient safety culture:

survey results ; International Journal of Health Care Quality Assurance Vol. 20 No. 7, 2007 pp. 620-632.

42Mehmet TolgaTaner and Bu lentSezen, An overview of six sigma applications in healthcare industry; International Journal of Health Care Quality Assurance Vol. 20 No. 4, 2007 pp. 329-340.

61

often undermine the delivery of safe, effective patient care. Integrating the six-sigma

culture into entire organizations by the commitment and involvement of top

management can multiply the positive effects and make a significant impact at all

levels. High level of internal communication is found necessary also necessary to

facilitate the implementation of six sigma. The established Quality Improvement Team

should collaborate with outside quality facilitators who can train them in deploying

implementation and to provide necessary training for all project participants in system

deployment, project management, and utilization of quality tools.

Ali Mohammad Mosadegh Rad (2005)43investigated the success of TQM and

barriers to its successful implementation in health care services organizations in

Isfahan province, Iran, 2004.In this study descriptive and cross-sectional research was

done via two questionnaires (TQM success and its barriers). The statistical population

of this research consisted of all managers of health care services organizations who

implemented TQM in their organizations (90 managers).It was found that TQM

success in Isfahan health care organizations was high. The correlation analysis

between the success of TQM and its principles, success, process management and

focus on employees had a positive and the greatest effect and focus on material

resources and on suppliers had a lower effect. In correlation analysis between the

barriers to TQM and the problem dimensions, human resource, strategic and structural

problems were the most important obstacles and barriers to TQM successful

implementation respectively.

Qianmei (May) Feng and Chris M. Manuel (2008)44 Medical and policy literature

reports many six sigma applications at specific healthcare organizations. However, there

is a lack of studies that investigate the broader status of six sigma in US healthcare

systems. The purpose of this paper is to present the results from a national survey of six

sigma programs in US healthcare organizations. Assessed the implementation of six

sigma in healthcare facilities. Two sets of surveys were designed based on whether an

organization has adopted six sigma or not. Indicated the common six sigma projects

43 Ali Mohammad Mosadegh Rad (2005), ‘A survey of total quality management in Iran Barriers to successful implementation in health care organizations’; eadership in Health Services Vol.

18 No. 3, 2005 pp. xii-xxxiv. 44Qianmei (May) Feng and Chris M. Manuel (2008), ‘Qianmei (May) Feng and Chris M. Manuel

(2008)’; International Journal of Health Care Quality Assurance Vol. 21 No. 6, 2008 pp. 535-547.

62

implemented in healthcare organizations, typical implementation durations, cost benefits,

and major barriers in implementation, and so on.

P. Gary Jarrett,Kaiser, Jacksonville (2006)45conducted research study to

recommend operational improvements to be achieved by implementing JIT Systems.

In this particular study the cost and benefit outcomes achieved from a health care JIT

implementation were compared with those achieved by the manufacturing, service,

and retail industries. Chiefly, it was found that the health service market must be

restructured to encourage greater price competition among priorities. A new

standardization process should eliminate duplication of products and realize

substantial savings.

Relatively speaking, there is a great deal of information and research done on the

application of RFID technology into the healthcare sector (Schwirn, 2006b, c)46.To

improve the healthcare supply chain by looking at possibilities of exploiting RFID

technology. With improvements, end customers and patients may receive better

service while mistakes in treatment of patients or underutilization of equipment in the

hospitals can be minimized. Many existing studies also suggest that proper

management of RFID technology implementation may enhance healthcare services

and products by lowering costs, improving the quality of care, and make patient care.

Sameer Kumar, Eric Swanson and ThuyTran (2009)47 showed that the cost of

implementing current RFID technology was too expensive for broad and sweeping

implementation within the healthcare sector at this time. Costs can be drastically

reduced and justified with the proper collaboration within the supply chain. Improving

relationships, sharing the high capital costs, and democratically choosing

technological standards will improve the likelihood of end users saving money and

receiving better service. However, several example applications had been identified in

which this technology could effectively leveraged in a cost-effective way. RFID

45 P. Gary Jarrett Kaiser, Jacksonville; LEADERSHIP IN HEALTH SERVICE (International health

care logistics) An analysis of international health care logistics The benefits and implications of implementing just-in-

time systems in the health care industry; Leadership in Health Services Vol. 19 No. 1, 2006 pp. i-x.

46Schwirn, M. (2006c), RFID Technology Map, SRI Consulting Business Intelligence, Menlo Park, CA, pp. 1-132.

47Sameer Kumar, Neha S. Ghildayal and Ronak N. Shah, Examining Quality and Efficiency of the U.S. Healthcare System; Emerald Group Publishing Limited.p.p.1-39.

63

technology has come a long way in the recent past and has potential to improve

healthcare sector productivity and efficiency.

2.3.2. Components of Hospital Management:

A systematic approach measuring, tracking, monitoring and continuously improving

efficiency, availability. There were three indicators availability (A), quality (Q) and

efficiency (E). Healthcare organizations must monitor, track and improve these

important aspects of their service operational system. The proposed approach

intended to facilitate the systematic improvement at the different facets of operational

effectiveness. Carlos F. Gomes et al.(2010)48

Dirk F. de Korne, Kees (J.C.A.) Sol, Thomas Custers (2009)49showed Quality

control model (QCM) and care delivery value chain (CDVC) tools for hospital

management to manage both on quality and cost outcomes in glaucoma care. Within

the CDVC approach, QCM can be used to facilitate the choice between quality

projects and provide focus on the potential reduction in costs of non-compliance. A

reduction of costs per product by increasing the number of outpatient visits and

surgery combined with a higher patient satisfaction. For CDVC to be supportive to an

integrated quality and cost management, the notion “patient value” needs far more

specification as mutually agreed on by the stakeholders involved and related

reimbursement needed to depend on realized outcomes.

The hospital’s identity as a health community is slowly being transposed to that of

an enterprise. Hospitals are getting bigger, are using relatively higher numbers of

non-medical employees, their customers are becoming more critical, and they are

operating in an increasingly competitive climate. J.R.C. van Sambeek and F.A.

Cornelissen (2010)50conducted a research study to find decision-making models

for the design and control of processes regarding patient flows, considering

48Carlos F. Gomes,Mahmoud M. Yasin,YousefYasin,; Assessing operational effectiveness in

healthcare organizations: a systematic approach, International Journal of Health Care Quality Assurance Vol. 23 No. 2, 2010 pp. 127-140.

49 Dirk F. de Korne, Kees (J.C.A.) Sol, Thomas Custers (2009), ‘Creating patient value in glaucoma care: applying quality costing and care delivery value chain approaches’; International Journal of Health Care Quality Assurance Vol. 22 No. 3, 2009 pp. 232-251.

50J.R.C. van Sambeek and F.A. Cornelissen (2010), Models as instruments for optimizing hospital processes: a systematic review; International Journal of Health Care Quality Assurance Vol. 23 No. 4, 2010 pp. 356-377.

64

various problem types, and to find out use of these models in decision making. A

total of 68 articles were selected. Of these, 31 contained computer simulation

models, ten contained descriptive models, and 27 contained analytical models. The

review showed that descriptive models are only applied to process design

problems, and that analytical and computer simulation models were applied to all

types of problems to approximately the same extent. Only a few models have been

validated in practice, and it seems that most models were not used for their

intended purpose i.e. to support management in decision making.

In 1996, two physicians at Harvard University concluded that “there is so far no

convincing scientific evidence that the application of the techniques of total quality

management in health care improves the quality of care in entire institutions or among

large numbers of physicians” (Blumenthal and Epstein, 1996)51.

Ranjita Misra and Arvind Modawal(2009)52concluded that fewer Asian-Indian

physicians practiced in areas of high market penetration by managed care and have

moderate satisfaction with their ability to deliver appropriate and quality care. The

experience was categorized into physician satisfaction; service quality rating;

service limitations; difficulties acquiring and maintaining managed care contracts;

and financial impact.

Gunilla Johansson, Stockholm, Sweden and Christer Sandah (2011)53

described the perceptions of registered nurses (RNs), enrolled nurses (ENs), and

leaders (i.e. the first-line nurse manager, F-LNM and the) as to what characterises

an excellent work environment in a palliative care unit and the involvement of

leadership in that environment. Data were collected using two separate

instruments: a questionnaire, group interviews with nurses and leaders, and

documents at a palliative care unit. Qualitative content analysis was used to

analyze the material. The emerging categories found were: congruence in

51Blumenthal, D. and Epstein, A.M. (1996), “Quality of health care.Part 6: the role of physicians

in the future of quality management”, The New England Journal of Medicine, Vol. 335 No. 17, pp. 1328-31.

52Ranjita Misra ,Arvind Modawal, Bhagaban Panigrahi; Asian-Indian physicians ‘experience with managed care organizations, International Journal of Health Care Quality Assurance Vol. 22 No. 6, 2009 pp. 582-599.

53GunillaJohansson,ChristerSandahl ,Birgitta ,Andershed,; Authentic and congruent leadership providing excellent work environment in palliative care, Leadership in Health Services Vol. 24 No. 2, 2011 pp. 135-149.

65

leadership, mature group functioning; adequate organizational structures and

resources; and comprehensive and shared meaning fullness. To accomplish the

vision of good palliative care. Similarly in leadership, mature group functioning,

adequate organisational structures and resources, and comprehensive and shared

meaningfulness were identified as essential components for fulfilling the vision.

Business Process Reengineering (BPR) as fundamentally rethinking and radically

redesigning business processes to achieve dramatic improvements in critical

contemporary performance measures such as cost, quality, service and speed. BPR,

also known business transformation and process change management. They found

BPR, like other single approached to improve service quality, were likely to be

unsuitable for health care, which is comprised of a number of sub processes. It has

many stakeholders at different levels and there is wide variation in its internal

customer (e.g., fellow professionals) and external customer (i.e. patients) needs.

(Anjali Patwardhan and Dhruv Patwardan ,2008)54.

2.3.3. Hospital governance

Corporate governance has been widely studied and has been identified as an important

determinant of organizational performance (Abor and Adjasi, 2007; Abor and Biekpe,

2007)5556.Health care organizations are looking to the leadership abilities of their

employees to ensure their success (Bodinson, 2005; Kim, 2007; Melum, 2002)575859.

Leadership development initiatives are a key strategy utilized to maximize leadership

behaviours; such initiatives often include sending employees to leadership development

programs (Block and Manning, 2007; Groves, 2007; Sharlow et al , 2009)60.

54Anjali PatwardhanDhruvPatwardhan ;Business process re-engineering – saviour or just another fad?

One UK health care perspective; A International Journal of Health Care Quality Assurance Vol. 21 No. 3, 2008 pp. 289-296 q Emerald Group Publishing Limited.

55Abor, J. and Adjasi, C. (2007), “Corporate governance and the small and medium enterprises sector: theory and implications”, Corporate Governance, Vol. 7 No. 2, pp. 111-22.

56Abor, J. and Biekpe, N. (2007), “Corporate governance, ownership structure, and performance of SMEs in Ghana: implications for financing opportunities”, Corporate Governance, Vol. 7 No. 3, pp. 288-300.

57Bodinson, G. (2005), “Change healthcare organizations from good to great”, Quality Progress , Vol. 38 No. 11, 22-29.

58Kim, S. (2007), “Learning goal orientation, formal mentoring, and leadership competence in HRD: A conceptual model”, Journal of European Industrial Training, Vol. 31 No. 3, pp. 181-194.

59Melum, M. (2002), “Developing high-performance leaders”, Quality Management in Health Care, Vol. 11 No. 1, pp. 55-68.

60Block, L. and Manning, J. (2007), “A systemic approach to developing frontline leaders in healthcare”, Leadership in Health Services , Vol. 20 No. 2, pp. 85-96.

66

Hospital governance has been defined to include the responsibility and accountability

for the overall operation of an organization (Bohen, 1995)61. More specifically,

hospital governance has been conceived of as a shared process of top-level

organizational leadership, policy making and decision making. Although the

governing board has the ultimate accountability, the CEO, senior management and

clinical leaders are involved in top-level functions (Bader, 1993; Alexander et al.,

2003)6263.Much of the efforts have been done to implement patients’ centric approach,

but this culture is not fully flourished. The observation of the office space revealed

that there is a lack of patient-centric artefacts in the corporate environment; this needs

to be corrected to align visual symbols with corporate vision and to reinforce the

patient-centric culture for the employees.(Steven H. Appelbaum, Seyed Mahmoud

Zinati, 2010)64.

Nancy Phaswana-Mafuya, George Petros, Karl Peltzer, (2008)65identified service

gaps were understaffing/lack of capacity, difficulty in retaining and recruiting staff,

service disparities, inaccessibility of services/low-service utilisation and limited

funding. It was believed that NPOs could fill these gaps. About 83 per cent perceived

the relationship between government and NPOs as good. Contract monitoring, quality

of service, communication and quality control were said to be unsatisfactory. The

majority of sub-districts (11) indicated that they provided supplies to NPOs; 50 per

cent perceived the relationship between the sub-districts and NPOs as good or very

good. NPOs have critical role to play in PHC service delivery.

Rubin Pillay( 2008)66addressed the problem of providing managers in both the public

and private sectors with the requisite competencies to help increase efficiency,

effectiveness and responsiveness in the delivery of health services. A cross sectional

61Bohen, L.S. (1995), Your Role as a Trustee, Ontario Hospital Association, Toronto. 62Bader, B.S. (1993), “CQI progress report”, Healthcare Executive, September-October, pp. 8-11. 63Alexander, J.A., Lee, S.Y. and Bazzoli, G.J. (2003), “Governance in health systems and health

networks”, Health Care Management Review, Vol. 28, pp. 228-43. 64Steven H. Appelbaum, Seyed Mahmoud Zinati,Andrew MacDonald and YusefAmiri (2010),

‘Organizational transformation to a patient centric culture: a case study’;Leadership in Health Services Vol. 23 No. 1, 2010 pp. 8-32.

65Nancy Phaswana-Mafuya, George Petros, Karl Peltzer, (2008), ‘Primary health care service delivery in South Africa’;International Journal of Health Care Quality Assurance Vol. 21 No. 6, 2008 pp. 611-624.

66Rubin Pillay( 2008), ‘A comparative analysis of the public and private sectors’;Leadership in Health Services Vol. 21 No. 2, 2008 pp. 99-110.

67

survey using a self administered questionnaire was conducted among hospital

managers in South Africa. Respondents were asked to rate the level of importance that

each proposed competency had in their job and to indicate their perceptions about the

adequacy of health management training programs in South Africa. Hospital

managers in both sectors felt that people management and self management skills

were the most valuable for the efficient and effective management of hospitals,

followed by “hard management skills” and skills related to the ability to think

strategically. Specific skills or knowledge related to health care delivery were

perceived to be least important. Public sector managers were also more likely to seek

future training, and were also more adamant about the need for future management

development programs.

Subhasis Ray AmitavaMukherje( 2007)67 conducted a research study to explore the

route map for employing efficient e-governance so that at least existing resource and

infrastructure are better utilized and deficiencies were tracked for future planning.

National health is one of the most important factors in a country’s economic growth.

India seems to be a victim of the vicious cycle around poor economy and poor health

conditions. A detailed study was carried out to find out India’s healthcare

infrastructure and its standing in e-governance initiatives. After consolidating the fact

that effective e-governance can enhance the quality of healthcare service even within

limited resources, authors explored success and failure factors of many e-governance

initiatives in India and abroad. Finally, an e-governance framework is suggested

based on the above factors together with the authors’ own experience of implementing

e-governance projects in India and abroad. The suggested framework is based on a

phased implementation approach. The first phase “Information Dissemination” is

more geared towards breaking the “digital divide” across three dimensions:

G2Business; G2Citizen; and G2Agent. The most advanced stage is aimed towards

joining up healthcare information across the above three dimensions and drawing

meaningful analytics out of it.

67Subhasis Ray Amitava Mukherje( 2007), ;‘Development of a framework towards successful

implementation of e-governance initiatives in health sector in India’; International Journal of Health Care Quality Assurance Vol. 20 No. 6, 2007 pp. 464-483.

68

Principle eight is known as “self-improvement and quality of management”. To

ensure total quality management, continuous improvement as an organizational

philosophy needs to permeate all aspects of the hospital (Taylor, 2000)68. This is

tested in public and private sector hospitals’ governance. The results of the study

revealed numerous differences in the governance structures in private and public

hospitals. Public hospitals employ large board size compared to the private hospitals.

The results obtained were analyzed and discussed to ascertain the extent to which the

governance structures in these hospitals conform to Taylor’s principles of good

governance. The results of the study revealed numerous differences in the governance

structures in private and public hospitals in Ghana. From the review of Taylor’s

principles of good governance and the comparative case analysis, it was observed that

some of the principles are not present in the current hospital governance systems

(Joshua Abor, 2008)69.

The two dimensions of institutional culture identified for this study were character and

leadership. The character of an institution was the unique identity of the institution that

distinguishes it from other institutions. It includes the “symbols, myths, visions, pride,

and the accomplishments of its past and present heroes” (Lusthaus et al., 1999)70.

Leadership is very important to the success of any institution. Lusthaus et al. (2002)71

defined leadership as “the process through which leaders influence the attitudes,

behaviors and values of others towards organizational goals” (Lusthaus et al., 2002)72.

2.3.4. Organizational Culture:

Hospitals apply several ways to improve quality such as flourishing culture that

enhances quality, attracting, and retaining qualified people, and empowering

68Taylor, D.W. (2000), “Facts, myths and monsters: understanding the principles of good governance”,

The International Journal of Public Sector Management, Vol. 13 No. 2, pp. 108-15. 69Joshua Abor(2008),; ‘An examination of hospital governance in Ghana’;Leadership in Health

Services Vol. 21 No. 1, 2008 pp. 47-60. 70Lusthaus, C., Adrien, M-H., Anderson, G. and Carden, F. (1999), Enhancing Organizational

Performance: A Toolbox for Self-assessment, International Development Research Centre, Ottawa.

71Lusthaus, C., Adrien, M.-H., Anderson, G., Carden, F. and Montalva ´n, G.P. (2002), Organizational Assessment: A Framework for Improving Performance, International Development Research Centre, Ottawa.

72 Ibid 84

69

employee (Silow-Carooll et al., 2007)73. The success of quality improvement

endeavors is expected to rely heavily on the type of organization culture (Ginsburg,

2003)74. Organizational culture was conceptualized as a construct that consists of

three distinctive subcultures: bureaucratic, innovative, and supportive (Wallach,

1983)75. In bureaucratic culture, there are clear lines of authority and hierarchy, and

work is highly regulated and systemized. Innovative culture is characterized as

involving creativity, freedom, results-oriented, and risk-taking. Supportive culture

provides friendly and warm environment where employees tend to be open, fair, and

honest. Quality improvement focuses mainly on leadership support, processes, human

resource, information, customer focus, and innovation to achieve high quality in

health care organizations (Meurer et al., 2002)76.Organizational culture has been

defined as shared behaviours, values, and beliefs that are learned by the members of

an organization (Lawson and Ventriss, 1992)77. Organization culture has the

potential to shape attitudes, reinforce beliefs, direct behaviour, and establish

performance expectations. The best organizations have strong cultures that encourage

adaptability and continuous improvement in all areas of operation (Adams, 2009)78.

Each organization usually has a dominant culture, which expresses the core values

that are shared by a majority of its members. Bureaucratic subculture is usually

dominated by rules, regulations, and orders, where employees are requested to

perform tasks as specified without freedom or autonomy. The innovative subculture,

in contrast, values the talents, ideas, and creative potential of all members.

73Silow-Carooll, S., Alteras, T. and Meyer, J. (2007), Hospital Quality Improvement: Strategies and

Lessons from US Hospitals, Health Management Association, Brussels. 74Ginsburg, L. (2003), “Factors that influence line managers’ perceptions of hospital performance

data”, Health Service Resources, Vol. 38, pp. 261-86. 75Wallach, E. (1983), “Individuals and organization: the cultural match”, Training and Development

Journal, Vol. 12, pp. 28-36. 76Meurer, S., Rubio, D., Counte, M. and Burroughs, T. (2002), “Development of a healthcare quality

improvement measurement tolls: results of a content validity study”, Hospital Topics: Research and Perspectives on Healthcare, Vol. 80 No. 2, pp. 7-13.

77Lawson, R. and Ventriss, C. (1992), “Organizational change: the role of organizational culture and organizational learning”, Psychological Record, Vol. 42 No. 2, pp. 208-18.

78Adams, L. (2009), “The role of health information technology in improving quality and safety in RI: can new money solve old problems?”, Medicine and Health Rhode Island, Vol. 92 No. 8, August, pp. 267-8.

70

2.4 Service Quality

Service quality is a principles component of customer satisfaction. Consumer’s

perception is the main determinant of quality in health care service. Most of the

researchers on that issue believe that there is a relationship between the perception of

the consumers on the quality of the services and their satisfaction (Cronin &Taylor,

1994)79.

Quality of health care is the most optimal degree of health outcomes by delivery of

effective, efficient and cost-benefit professional health services to people and

communities.

As there are many alternatives to patients for hospital choices. If they are not satisfied

with one they can easily choose another provider. Conceptualizing and measuring

customer satisfaction and service quality in a health care setting more important and

simultaneously more complex (Taner and Antony, 2006)80.

Almost all studies stress the importance of patients’ views as an essential tool in the

processes of monitoring and improving quality of healthcare services. Many hospitals

increasingly are adopting a patient-centered attitude (Hendriks et al., 2002)81.

Applying quality management tools and techniques to improve performance is

relatively new to intensive care services. Peer-review process, a common method to

identify ICU defecates. Seetharaman Hariharan, Prasanta Kumar Dey

(2010)82introduced a quality management framework by combining cause and effect

diagram and logical framework. An intensive care unit was identified for the study.

They found that patients improved infrastructure, state-of-the-art equipment, well

maintained facilities, IT-based communication, motivated doctors, nurses and support

staff, improved patient care and improved drug availability were considered the main

79Cronin, J.J. Jr and Taylor, S.A. (1994) “ SERVPERF versus SERVQUAL: Reconciling Performance-

Based and Perceptions-Minus- Expectations Measurement of Service Quality.” Journal of Marketing 58(1): 125- 31.

80Taner, T. and Antony, J. (2006), “Comparing public and private hospital care service quality in Turkey”, Leadership in Health Service, Vol. 19 No. 2.

81Hendriks, A., Oort, F., Vrielink, M. and Smets, E. (2002), “Reliability and validity of the satisfaction with hospital care questionnaire”, International Journal for Quality in Health Care, Vol. 14 No. 6, pp. 471-82.

82Seetharaman Hariharan, Prasanta Kumar Dey (2010), ‘A comprehensive approach to quality management of intensive care services’; International Journal of Health Care Quality Assurance Vol. 23 No. 3, 2010 pp. 287-300.

71

project outputs for improving performance. The proposed framework was used as a

continuous quality improvement tool, providing a planning, implementing,

monitoring and evaluating framework for the quality improvement measures on a

sustainable basis.

Barbara Treris(2010)83tried to describe the intentional and sustained strategy of

Providence Health Care to build a culture focused on quality, safety and innovation. It

was that found that the journey was in progress, significant improvements have been

accomplished.

Sameer Kumar, Neha S. Ghildayal and Ronak N. Shah(2011)84studied quality and

efficiency of U.S. healthcare services. The impact of quality and efficiency was examined

on various stakeholders to achieve the best value for each dollar spent for healthcare. It

was found thatthe U.S. healthcare system was of vital interest to the nation’s economy

and government policy (spending). The U.S. healthcare system was characterized as the

world’s most expensive yet least effective as compared to other nations.

Growing healthcare costs had made millions of citizens vulnerable. Major drivers of

the healthcare costs were institutionalized medical practices and reimbursement

policies, technology induced costs and consumer behaviour.

Amira Elleuch( 2008)85tried to measure patient satisfaction in Japan. Japanese

healthcare service quality was evaluated using its process characteristics (patient-

provider interaction) and physical attributes (settings and appearance). Process quality

attributes found to be patient satisfaction antecedents. Satisfaction in turn predicts

patient intentional behaviour (to return and to recommend). Japanese society cultural

specificity seems to be an interesting background to understand Japanese evaluation

when patients assess health service quality.

83Barbara Treris (2010), ‘Establishing an organizational culture to enable quality improvement’;

Leadership in Health Services Vol. 23 No. 2, 2010 pp. 130-140. 84Sameer Kumar, Neha S. Ghildayal and Ronak N. Shah (2011), ‘Examining Quality and Efficiency of the

U.S. Healthcare System’; International Journal of Health care quality Assuarance, Vol.24,No.5,pp.366-388.

85AmiraElleuch( 2008), ‘Patient satisfaction in Japan’; International Journal of Health Care Quality Assurance Vol. 21 No. 7, 2008 pp. 692-705 .

72

Quality of health care is the degree of the most optimal degree of health outcomes by

delivery of effective, efficient and cost-benefit professional health services to people and

communities.

Bodil Wilde-Larsson(2009)86found approximately 10 per cent hesitated about

continuing to visit the same care provider. Favourable service quality evaluations

made a statistically significant contribution to the odds of reporting no hesitation

about re-visiting the same primary healthcare centre.

To address today’s concerns with fragmentation of health services and uncoordinated

patient care the solution again often proposed is the development of integrated

delivery systems. There should be integrated delivery systems with incentives for

teams of professionals to provide coordinated, efficient, evident-based care.

Havva Çaha (2010)87found Patients preferred private hospitals due to their belief that

private hospitals provide qualitative health service in Turkey. But this did not mean

that they encounter sufficient services. On the contrary, a large number of patients

complain about services given by private hospitals. The complaints were mainly about

the length of the time that they wait for treatment and the consultation time given to

them. As a result, this study indicated that satisfaction of the patients seem to be the

most important factor for the private health care providers.

Masood A. Badri and SamaaTaherAttia(2008)88found that if patients were given

information about their condition and about how to look after themselves in future, it

would help them to assume greater responsibility for their health. It was found that

both availability and access of resources; and rules, regulations and administrative

matters were important. Competency, knowledge, reliability and trust;

professionalism and courtesy; empathy and personal attention; and tangibles and

facilities formed a construct (named Care quality) proved important in third model.

The final recommended model was based on three constructs – quality of care,

86Bodil Wilde-Larsson (2009), ‘Patients’ views on quality of care and attitudes towards re-visiting

providers’; International Journal of Health Care Quality Assurance Vol. 22 No. 6, 2009 pp. 600-611.

87HavvaÇaha (2010), ‘Service Quality in Private Hospitals in Turkey’; Journal of Economic and Social Research 9(1), 55-69.

88Masood A. Badri and SamaaTaherAttia (2008), ‘Testing not-so-obvious models of healthcare quality’; International Journal of Health Care Quality Assurance Vol. 21 No. 2, 2008 pp. 159-174.

73

process and administration, and information. The goodness-of-fit statistics supported

the basic solution of the healthcare quality-satisfaction model.

Patients are usually in disequilibria when it comes to illness, which means that they are

not thinking in their normal pattern (Potter and Perry, 1997)89.This, in turn, affects not

only the individual but also the family, work environment and society as a whole. In the

current business environment, relationship marketing has become an important aspect of

doing business. This is especially true for a service business where high amount of

customer-employee relationship can influence the consumption of services offered.

Keeping a good relationship with customers is crucial for the success of the business

because it has the potential to increase customer retention rates.

2.4.1 Importance of customer Relationship

It can be ten times more expensive to win a customer than to retain a customer – and

the cost of bringing new customer to the level of profitability as the lost one is up to

16 times more (Lindgreen et al., 2000)90. In any situation involving people, one

aspect that needs to be given proper attention is interpersonal relationship. Based on

the inseparability characteristic of service, naturally service has significant impact on

customers. When a service is difficult to evaluate, consumers often look too their

cues, such as aspects of interaction or interpersonal method in assessing service

quality (Parasuraman et al., 1985)91.Relationship quality is viewed as a bunch of

intangible value that increases products or services and results in an expected

interchange between buyers and sellers.

2.4.2. Importance of Respect:

The word “respect” is common in our everyday usage. As mentioned earlier, the word

is very commonly used and each time when “respect” is mentioned, it is as if

everyone understands. On the other hand, in the actual academic world, to understand

“respect” is very complex. Even though the term respect is widely used in the society,

its dimensions and operationalization are unclear. Even though respect can be

89Potter, P.A. and Perry, A.G. (1997), “Fundamental Nursing. Concepts, process, and practice”.

Missouri: Mosby. 90Lindgreen, A., Davis, R., Brodie, R.J. and Buchanan-Oliver, M. (2000), “Pluralism in contemporary

marketing practice”, The International Journal of Bank Marketing, Vol. 18 No. 6, pp. 294-308. 91Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), “A conceptual model of service quality and

its implications for future research”, Journal of Marketing, No. 49, pp. 41-50.

74

considered as an “old” concept judging from the extensive usage of the word itself,

respectful behaviours actually varies by dentition and making it a deceiving complex

concept after all (Sung, 2004)92.

Respect may be viewed as caring which has the feeling of care and loving towards

others. Marketers always respect customers. It is unique blend of morality,

compassionate, responsive and caring for other individual (Dillon,1992)93.Care is

known as “meeting the others morally”(Noddings,1984)94.

Dillon (1992)95 proposes a concept with three dimensions; namely attention and

valuing of the particularity, understanding and responsibility. Dillon believes the

combination of the three dimensions will produce a kind of respect that we (as

individuals) owe to all, and not just our loved ones (1992). The dimensions of respect

in this study include: (1) attention and valuing; (2) understanding; and (3)

responsibility It involves an acceptance of the differences of others that goes beyond

toleration. Attention here also carries the need to be sympathetic, cherishing and

concern to be involved in engagement with participation of others. All in all, this

dimension urges the need to value differences in others and of viewing it as a barrier

to be overcome (Dillon, 1992)96.

92Sung, K.-T. (2004), “Elder respect among young adults: a cross-cultural study of Americans and

Koreans”, Journal of Aging Studies, No. 18, pp. 215-30. 93 ibid 94Noddings, N. (1984), Caring: A Feminine Approach to Ethical Moral Education, University of

California Press, Berkeley, CA. 95Dillon, R.S. (1992), “Care and respect”, in Cole, E.B. and Coultrap-McQuin, S. (Eds), Explorations

in Feminist Ethics, Indiana University Press, Bloomington. 96Dillon, R.S. (1992), “Care and respect”, in Cole, E.B. and Coultrap-McQuin, S. (Eds), Explorations

in Feminist Ethics, Indiana University Press, Bloomington,

75

Fig.-2.1 Relationship between Respect, Rapport building to Relationship quality

Source: Siti Haryati Shaikh Ali and Nelson Oly Ndubisi(2011)

Magriet Holder (2008)97A quasi-experimental design was used. An experimental and

control group (of patients) were surveyed before the changes in services cape took

place, and a further experimental and control group of patients were surveyed after

changes in the services cape. The results indicated the positive effect that the change

in the services cape had on the overall perceptions of service quality, as well as on

some of the individual dimensions. In this study, it was possible to determine the

specific effects that changes in physical evidence had on the perceptions of service

quality as a whole, as well as on the various dimensions. The study confirmed the role

of physical evidence in the patient’s perceptions of service quality, as well as in the

patient’s perceptions of the reliability and responsiveness dimensions.

2.4.3. Rapport

Rapport is such a familiar concept that almost everyone can identify with. It is a

human interaction including marketing, psychology and education. Many studies have

been done in education. In marketing management rapport is studied from selling

97Magriet Holder (2008), ‘The effect of changes in service scape and service quality perceptions in a

maternity unit’; International Journal of Health Care Quality Assurance Vol. 21 No. 7, 2010 pp. 631-642.

Respect

Attention and valuing

to the particularity

Understanding

Responsibility

Rapport building

Relationship

quality

76

point of view. The definition by Gremler and Gwinner (2000)98 was much more

relevant to marketing. They defined rapport as the character of the interaction

between employees and customers. Among others, they suggested that rapport

consists of two important dimensions; namely enjoyable interaction and personal

connection. Both were perceived by customers and employees as important in the

development of relationships in service contexts. Enjoyable interaction refers to “an

affect laden cognitive evaluation of one’s exchange with employee.”

Recent changes in the competitive environment have forced industries to formulate

new strategic responses. Service quality is a multi-dimensional construct. Thus,

service quality may be viewed based on the different attributes of the service delivery

system in different operational context. These responses are known as operational

philosophies aimed at improving internal efficiency and external effectiveness. These

philosophies included quality improvement initiatives such as, total quality

management (TQM), just in time (JIT), continuous improvement (CI), job

reengineering (JR), process reengineering (PR), organizational restructuring (OR),

benchmarking (BM), among others. Jafar Alavi and Mahmoud M. Yasin

(2008)99aimed at understanding the effective implementation of quality improvement

initiatives in different service operational settings. With the specific environmental,

strategic and operational realities and challenges faced by healthcare related

organizations this study specifically attempted to shed some light on the role of

effective implementation of quality improvement initiatives in addressing the

operational, environmental and strategic challenges faced by these organizations. The

results of the environmental changes factor analysis tend to confirm the current

environmental challenges faced by most healthcare related organizations. It is to be

noted that the customer, innovation and governmental regulations represent the

backbone of these environmental changes. The results of factor analysis related to

strategic options appeared to indicate that the studied organizations were aware of

these challenges, as they had developed quality improvement-based strategies to deal

with such environmental changes. Finally, the effectiveness of the implemented 98Gwinner, K.P., Gremler, D.D. and Bitner, M.J. (1998), “Relational benefits in services industries: the

customer’s perspectives”, Academy of Marketing Science, Vol. 26 No. 2, pp. 101-14. 99JafarAlavi and Mahmoud M. Yasin (2008), ‘The role of quality improvement initiatives in healthcare

operational environments Changes, challenges and responses’ (International Journal of Health Care Quality Assurance Vol. 21 No. 2, 2008 pp. 133-145.

77

quality improvement initiatives, both in terms of operational outcomes, as well as

strategic outcomes appeared to be the norm rather than the exception.

Fig. 2.2 Quality improvement strategies

Source: JafarAlavi and Mahmoud M. Yasin (2008)

Hospitals are required to provide patients with the highest quality service at the lowest

possible cost. Both public and private health organizations face several challenges that

force them to be more customer-focused and to be highly responsive to global

changes. Accordingly, health care organizations are forced to respond to the growing

pressure on the health system for demonstrably high and ever improving standards of

care and services (Balding, 2007)100. Patient safety and quality improvement are

becoming important criteria for accreditation decisions by international and local

health care organizations around the world. Indeed, the primary objective of quality

improvement in health organizations is to provide excellence for patients through

continuous improvement of services.

Quality improvement is an organization wide commitment that entails the training and

involvement of all employees in quality-related activities. Quality improvement

should cover all processes conducted in health organizations. Because quality

improvement is concerned clearly with making the process better instead of blaming

people, it requires that employees understand the nature of the core processes used to

100Balding, M. (2007), A Model for Middle Manager: Led Quality Improvement in Health Care, The

Royal Victorian Eye and Ear Hospital, Melbourne.

Environmental

Change

Healthcare

Industry

Competitive

Response

Implentation of

Quality

Improvement

Initiatives

Oragnisational

Benefits

78

provide health care. In addition, the hospital’s investment in the people and the

systems are necessary to measure and improve quality (Craven et al., 2006)101.

Raed Ismail Ababaneh( 2010)102The study results revealed that innovative culture

plays a stronger role compared with bureaucratic and supportive cultures in quality

improvement practices in Jordanian public hospitals. Contrary to previous research

(Kissam et al., 2003)103, bureaucratic culture showed a positive correlation with each

dimension of quality improvement. Compared with bureaucratic and supportive

cultures, innovative culture appears to play a stronger role in quality improvement

practices. Contrary to expectations, the analysis showed that bureaucratic actions

enhance rather than hinder quality improvement practices.

Consumers may get free and easy health information from the Internet or

advertisements this has changed the traditional dynamics between patients and

physicians. Managed care offers an open access to and broad choice of providers to

the patient. Thus, the healthcare market has become a consumer-driven market under

the managed care system. Marketing information system can facilitate the providers

to redesign areas for improvement and enhancement of their caring process and, in

turn, patient satisfaction.

Sandra S. Liu,Hyung T. Kim,Jie Chen And Lingling An(2010)104

In this study, there were five CQAs, or factors identified: Communication and

Empowerment, Compassionate and Respectful Care, Clinical Reputation, Care

Responsiveness, and Efficiency. The promotion detraction matrix demonstrated the

stronger promotion effects of Compassionate and Respectful Care and Efficiency; and

major detraction effect of Clinical Reputation and Communication and

Empowerment. That was, improving Compassionate and Respectful Care and

101Craven, E., Clark, J., Cramer, M., Corwin, S. and Cooper, M. (2006), “New York Presbyterian hospital uses

Six Sigma to build a culture of quality and innovation”, Journal of Organizational Excellence, Vol. 7, pp. 11-19.

102Raed Ismail Ababaneh( 2010), ‘The role of organizational culture on practising quality improvement in Jordanian public hospitals’; Leadership in Health Services Vol. 23 No. 3, 2010 pp. 244-259.

103Kissam, S., Gifford, D., Parks, P., Patry, G., Palmer, L., Wilkes, L., Fitzgerald, M., StollenwerkPetrulis, A. and Barnette, L. (2003), “Approaches to quality improvement in nursing homes: lessons learned from the six-state pilot of CMS’s nursing home quality initiative”, BMC Geriatrics, Vol. 3 No. 2, pp. 1-8.

104Sandra S. Liu,Hyung T. Kim,Jie Chen And Lingling An(2010), ‘Uisualizing Desirable Patient Healthcare Experiences’; Health Marketing Quarterly, 27:116–130, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 0735-9683.

79

Efficiency could significantly promote the recommendation of the service; whereas

lowering the perceived level Clinical Reputation, Communication, and Empowerment

would detract patients from recommending or utilizing the services.

Quality improvement is an important aspect of any service but sometimes specific

quality improvement process changes may have little impact on an organization’s

bottom line and may actually reduce employee satisfaction and thus bottom-line

performance. (Anne S. York and Kim A. McCarthy, 2011)105

2.5. SERVQUAL

According to the SERVQUAL model, the quality is determined by evaluating the

relationship between the expected and the actual and a reflection of the deviations.

Marketers advocate a functional approach when it comes to measuring service quality.

Parasuraman et al. (1985)106 observed that service was difficult to anticipate and

comprehend what aspects insinuate high quality to consumers, and the levels of those

aspects that required to deliver high-quality service.

2.5.1. SERVQUAL as power tool:

Customer satisfaction and service quality research is dominated by SERVQUAL,

which suggests that service quality is fundamentally a gap between customer

expectations regarding a service provider’s general class and their estimation of its

actual performance (Parasuraman et al., 1991a)107

The original objective in the development of SERVQUAL was to try to provide an

instrument for measuring service quality that could be used across a broad range of

services and industries with only minor modification. SERVQUAL to date has been

applied across a range of private sector organizations (Babakus& Boiler, 1992;

Bouman& van der Wiele, 1992; Candlin& Day, 1993)108

105 Anne S. York and Kim A. McCarthy, 2011, Patient, staff and physician satisfaction: a new model,

instrument and their implications; International Journal of Health Care Quality Assurance Vol. 24 No. 2, 2011 pp. 178-191.

106Parasuraman, A., Zeithaml, V.A. & Berry, L.L. (1985) A conceptual model of service quality and its implications for future research, Journal of Marketing, 49, pp. 41± 50.

107Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1991a), “Refinement and reassessment of the SERVQUAL scale”, Journal of Retailing, Vol. 67 No. 4, pp. 420-50.

108BABAKUS, E. & MANGOIX), W.G. (1992) Adapting the SERVQUAL scale to hospital services: an empirical investigation, Health Services Research, 26, pp. 767-786.

80

In their study, Reidenback and Sondifer- Smallwood109 identified patient

confidence as one of the dimensions affecting patient satisfaction in all the above-

mentioned three settings. Patient confidence also influences the perception of service

quality in both the inpatient and outpatient settings.

The SERVQUAL instrument of Parasuraman et al. (1988)110, a 22-item scale that

measures service quality along dimensions, forms the keystone for all the other works.

Though the effectiveness of SERVQUAL in evaluating service quality has been

questioned by different authors for diverse reasons, there is a general agreement that

the 22 items are reasonably good predictors of service quality in its entirety. The

SERVQUAL was designed using the five nursing services identified in other studies

as the essential elements in providing a quality nursing service. These elements are:

tangibles, reliability, responsiveness, assurance and empathy.

Johnstone (1995)111 extended the five generic dimensions of SERVQUAL up to

eighteen quality dimensions viz. cleanliness, aesthetics, comfort, functionality, reliability,

responsiveness, flexibility, communication, integrity, commitment, security, competence,

courtesy, friendliness, attentiveness, care access and availability.

Lim and Tang (2000)112developed a modified SERVQUAL model considering six

dimensions viz. tangibles, reliability, assurance, responsiveness, empathy,

accessibility and affordability. They have put emphasis on affordability of patients

relating to their satisfaction.

SERVQUAL provides service managers and associated decision- makers not only with

information on customer perceptions of current service delivery but also on their

expectations, thus enabling a closer matching of service delivery to expectations and needs.

Similarly, the SERVQUAL instrument is capable of application to different customer

109Reidenback ER, Sandifer-Smallwood B (1990).Exploring perceptions of hospital operations by a

modified SERVQUAL approach. J. Health Care Mark. 10(4): 47-55 110Parasuraman, A., Zeithaml, V.A. & Berry, L.L. (1988) SERVQUAL: a multiple-item scale for

measuring consumer perceptions of service quality, Journal of Retailing, Spring, pp. 12± 40. 111Johnston R (1995). The determinants of service quality satisfiers and dissatisfies. Int. J. Serv. Ind.

Manage., 6(5): 53-71. 112Lim, P. and Tang, N. (2000), A study of patient’s expectations and satisfaction in Singapore

hospitals’, International Journal of Health Care Quality Assurance 13 (7), 290-299.

81

groups of the same service provider, again allowing better informed prioritization and

priority conflict resolution. (Mik Wisniewski & Mike Donnelly, 1996)113

Especially in the event of time and resource constraints, the SERVQUAL scale is able

to direct managerial attention to service areas which are critically deficient from the

customers’ viewpoint and require immediate attention. No doubt, the SERVQUAL

scale entails greater data collection work. (Dabholkar, Shepherd and Thorpe,

2000)114.

SERVPERF, is named expectation (E) component of SERVQUAL be discarded and

instead performance (P) component alone be used. They proposed what is referred to

as the ‘SERVPERF’ scale. Besides this is the SERVQUAL scale which entails

superior diagnostic power to pinpoint areas for managerial intervention. The obvious

managerial implication emanating from the study findings is that when one is

interested simply in assessing the overall service quality of a firm or making quality

comparisons across service industries, one can employ the SERVPERF scale because

of its psychometric soundness and instrument ungenerousness. However, when one is

interested in identifying the areas of a firm’s service quality shortfalls for managerial

interventions, one should prefer the SERVQUAL scale because of its superior

diagnostic power. No doubt, the use of the weighted SERVQUAL scale is the most

appropriate alternative from the point of view of the diagnostic ability of various

scales, yet a final decision in this respect needs to be weighed against the gigantic task

of information collection.(Sanjay KJain and Garima Gupta,2004)115.

Mik Wisniewski & Mike Donnelly (1996)116found V.Parasuraman et al. designed

the SERVQUAL instrument to apply across the spectrum of service environments

with a minimum of adaptation. The underlying structure of the SERVQUAL

instrument appeared well suited to assessing service quality in a public sector context. 113Mik Wisniewski & MIKE DONNELLY,1996,Measuring service quality in the public sector: the

potential for SERVQUAL;TOTAL QUAUTY MANAGEMENT, VOL. 7, NO. 4, 1996, p.p.357-365.

114Dabholkar, P A, Shepherd, D C and Thorpe, D I (2000). “A Comprehensive Framework for Service Quality: An Investigation of Critical, Conceptual and Measurement Issues through a Longitudinal Study,” Journal of Retail- ing, 76(2), 139-73.

115Sanjay K Jain and Garima Gupta(2004), Measuring Service Quality: SERVQUAL vs. SERVPERF Scales; VIKALPA • VOLUME 29 • NO 2 • April - June 2004 p.p25-37.

116MiK WiSNiEWSKi& MIKE DONNELLY,1996, Measuring service quality in the public sector: the potential for SERVQUAL; TOTAL QUAUTY MANAGEMENT, VOL. 7, NO. 4, 1996, 357-365.

82

Potentially, it provided service managers and associated decision makers not only

with information on customer perceptions of current service delivery but also on their

expectations, thus enabling a closer matching of service delivery to expectations and

needs. Similarly, the SERVQUAL instrument was capable of application to different

customer groups of the same service provider, again allowing better informed

prioritization and priority conflict resolution. However, it was evident that further

applications of SERVQUAL to public sector services are required to assess the

portability and reliability of the approach. It appeared that further applications of the

SERVQUAL instrument to other public sector services and across different customer

groups for a particular service helped in the evaluation of the suitability of the existing

instrument.

2.5.2. SERVQUAL in Healthcare sector:

Wan Edura Wan Rashid (2009)117revealed SERVQUAL appeared to be a consistent

and reliable scale to measure heath care service quality. In principle, together with the

information relative significance of service quality dimensions, it helped health care

organization to identify where, and to some extent how, to improve the service they

offered to patients. Given the importance of functional aspects of care, the

SERVQUAL instrument had a useful diagnostic role to play in assessing and

monitoring service quality in health care, enabling the organization to identify where

improvements are needed from the patient’s viewpoint.

Hardeep Chahal (2007)118worked on the case study of Civil Hospital Ahmedabad.

The data was collected from 205 indoor patients of four departments namely general

medicine, orthopaedic, paediatrics, obstetrics and gynaecology. Inter and intra

relationship among the measures of service quality and patient loyalty were analyzed

by using relevant statistical tools to draw out inferences. Among the three patient

loyalty components, using provider again for the same services is found to be more

significant followed by using provider again for different services and recommending

providers to others in relation to overall service quality as dependent variable, and

117 Wan Edura Wan Rashid (2009), ‘Service quality in health care setting’; International Journal of

Health Care Quality Assurance Vol. 22 No. 5, 2009 pp. 471-482. 118Hardeep Chahal (2007), ‘Predicting patient loyalty and service quality relationship: a case study of

civil hospital, Ahmedabad, India’; Vision—The journal of business perspective l vol. 12 l no. 4 l October–December 2008.

83

beta values are figured out as 0.15, 0.12 and 0.09 respectively. The 35% R Square

value for the model service quality – patient loyalty model indicate weak predictive

power of this model. However at the same juncture the study found that no significant

difference in the patients’ perceptions with respect to patient loyalty and quality and

per se, may be concluded that both are identical measures. Alternatively the more

satisfied the patients are with the quality of their interactions with staff, the more

likely they are going to take treatments for similar and different medical problems and

would recommend the provider to their relatives and friends.

Rooma Roshnee Ramsaran-Fowdar (2008)119used a new service quality instrument

called PRIVHEALTHQUAL emerged from the study, based on factor and reliability

analysis. The “reliability and fair and equitable treatment” factor was found to be the

most important healthcare service quality dimension.

Shyh-Jane Li, Yu-Ying Huang, Miles M. Yang (2011)120 examined whether

satisfaction moderates the relationship between service quality and behavioural

intentions. A structured questionnaire was distributed to the out-patients of 12

regional hospitals (the middle level) in Taiwan. The findings showed that the different

dimensions of service quality (i.e. reliability, responsiveness, assurance, and

empathy). Satisfaction was positively moderated the influence of reliability/empathy

on behavioural intentions, but negatively moderates the relationships between

responsiveness/assurance and behavioural intentions. This study revealed the

moderating role of satisfaction in the translation from service quality to behavioural

intentions in health care services. Moreover, the natures of the moderating effects are

not the same for different service quality dimensions.

Shieu-Ming Chou, Thai-Form Chen, Beth Woodard(2005)121 studied to

determine the extent of disconfirmation of the perceived quality of nursing services,

and its relationship to patient’s satisfaction, intent to return, and intent to recommend

119Rooma Roshnee Ramsaran-Fowdar (2008), ‘The relative importance of service dimensions in a

healthcare setting’; International Journal of Health Care Quality Assurance Vol. 21 No. 1, 2008 pp. 104-124

120Shyh-Jane Li, Yu-Ying Huang, Miles M. Yang (2011), ‘How satisfaction modifies the strength of the influence of perceived service quality on behavioral intentions’; Leadership in Health Services Vol. 24 No. 2, 2011 pp. 91-105

121Shieu-Ming Chou Zhai-Form Chen, Beth Woodard, Miao-Fen Yen, Using SERVQUAL to Evaluate Quality Disconfirmation of Nursing Service in Taiwan; Journal of Nursing Research Vol. 13, No. 2, 2005p.p75-83.

84

to others. The results revealed age, gender, and education levels of patients as major

influences on individual perceptions of nursing care. Empathy was one service across

all sites that constantly scored highest in terms of satisfaction, both on the

SERVQUAL and in the interviews.

Simon S. K. Lam(1997)122found SERVQUAL appeared to be a consistent and

reliable scale to measure health care service quality. The scale exhibited reliable and

valid measures of patients' expectations of health care services and their perceptions

of the health care providers' performance level. The results pinpointed areas for

attention to improve health care service quality. First, they indicated that perceived

service performance generally falls short of idealized expectations except in the

physical elements of service quality. Timely, professional and competent service was

what the customers expect from health care providers, and although hospitals in Hong

Kong were generally provided good services in these three areas, improvements were

still needed to meet patients' expectations. The results also indicated patients'

perception that hospital staff showed not enough caring and that they were not

provided with individualized attention. These were the areas that hospitals should

have improved in order to build a patient focused attitude towards service delivery.

Healthcare service quality research, using the SERVQUAL model, brings mixed

results. Few have found SERVQUAL a reliable instrument, while others suggest there

are certain healthcare service dimensions that are not captured by the original

SERVQUAL scale (Babakus and Mangold, 1992;)123 . Therefore, it is important to

tailor the SERVQUAL scale to a sector’s specific needs, culture or nation.(Mohsin

Muhammad Butt , Ernest Cyril de Run,2009)124.

Mohsin Muhammad Butt and Ernest Cyril de Run (2010)125examined of 340

randomly selected participants visiting a private healthcare facility during a three-

month data collection period. Data were analyzed using means, correlations, principal

122SIMON S. K. LAM,1997, SERVQUAL: A tool for measuring patients' opinions of hospital service

quality in Hong Kong; TOTAL QUALJTY MANAGEMENT, VOL. 8, NO. 4, 1997, 145-152. 123Babakus, E. and Mangold, W.G. (1992), “Adapting the SERVQUAL scale to hospital services: an

empirical investigation”, Health Services Research, Vol. 26 No. 6, pp. 767-88. 124Mohsin Muhammad Butt and Ernest Cyril de Run, Private healthcare quality: applying a

SERVQUAL model; International Journal of Health Care Quality Assurance Vol. 23 No. 7, 2010 pp. 658-673

125 Ibid95

85

component and confirmatory factor analysis to establish the modified SERVQUAL

scale’s reliability, underlying dimensionality and convergent, discriminant validity.

Results indicated a moderate negative quality gap for overall Malaysian private

healthcare service quality. Results also indicated a moderate negative quality gap on

each service quality scale dimension. However, scale development analysis yielded

excellent results, which could be used in wider healthcare policy and practice.

Nowadays hospital are turning towards contracting options in order to reduce the

amount of capitation that goes into funding for laboratory work, technical support and

other services. Kidney dialysis machines, magnetic resonance imaging, transplant

techniques, nuclear medicine and high dosage chemotherapy are examples of

technological advances in recent years. Many of these technological advances involve

highly specialized and expensive equipment. When hospitals invest in equipment,

hospital costs – the most rapidly escalating element of healthcare costs – must then

increase. Medical professionals and their patients by the quality of the healthcare

professionals who serve them judged hospitals. The results suggested that specialty

hospitals were significantly more efficient than general hospitals. Overall, general

hospitals were found to be more than twice as inefficient compared with specialty

hospitals in the sample. (Sameer Kumar, 2010)126

Woo Hyun Cho, Hanjoon Lee, Chankon Kim, Sunhee Lee (2003)127examined the

relative impact of four service quality dimensions on outpatient satisfaction and to test

the invariance of the structural relationships between the service quality dimensions

and satisfaction across three patient groups of varying numbers of prior visits to the

same hospital as outpatients. Survey of 557 outpatients using a self-administered

questionnaire over a 10-day period at a general hospital in Sungnam, South Korea.

Patients answered questions related to two main constructs, patient satisfaction and

health care service quality. The health care service quality measures (30items) were

developed based on the results of three focus group interviews and the SERVQUAL

scale, while satisfaction (3 items) was measured using a previously validated scale.

126Sameer Kumar (2010) International Journal of Health Care Quality Assurance Vol. 23 No. 1,

2010pp. 94-109. 127Woo Hyun Cho, Hanjoon Lee, Chankon Kim, Sunhee Lee, and Kui-Son Choi, The Impact of Visit

Frequency on the Relationship between Service Quality and Outpatient Satisfaction: A South Korean Study, HSR: Health Services Research 39:1 (February 2004).

86

Confirmatory factor analysis was used to assess the construct validity of the service

quality scale by testing convergent and divergent validity. A structural equation model

specifying the four service quality dimensions as exogenous variables and patient

satisfaction as an endogenous variable was estimated to assess the relative impact of

each of the service quality dimensions on satisfaction. This was followed by a multi

group LISREL analysis that tested the invariance of structural coefficients across

three groups with different frequencies of outpatient visits to the hospital. Findings

supported the causal relationship between service quality and satisfaction in the

context of the South Korean health care environment. The four service quality

dimensions showed varying patterns of impact on patient satisfaction across the three

different outpatient groups.

Dr Markanday Ahuja et al. (2011)128conducted a research study and results indicated

that the SERVQUAL scale could make a valuable contribution by enhancing the

understanding of the perceived quality of eye care services. The measurement scale also

served to identify symptoms and the underlying problems that inhibit the effective

provision of quality eye care services. Be in a better position to anticipate patients’

requirements rather than to react to patient’s dissatisfaction. Respondents to be the most

important dimensions of service quality had identified the attributes of reliability and

assurance. The responsiveness & tangibility dimensions were found to have negative gap

(perception minus expectation), implying that patients expectation of these two

dimensions of the eye care services are not met by eye hospitals in Haryana.

SERVQUAL is used to advice decision makers and policy makers regarding

improvements needed regarding patients’ expectation and perception. The highest

expectation and perception and lowest gap of quality is related to the tangibles

dimension, showing that the private hospitals have paid attention to the physical

aspects and infrastructures of care delivery. Their findings confirm two previously

carried out study results in Singapore and Malaysia .(Asghar Zarei1, et al. 2012)129.

128Dr.Markanday Ahuja, Dr.Seema Mahlawat, Dr.Rana Zehra Masood, Study of Service Quality

Management with ServqualModel: An Empirical Study of Govt/NGO’s eye hospitals in Haryana; Internationally Indexed Journal www.scholarshub.net Vol–II , Issue -2 March 2011

129Asghar Zarei1, Mohammad Arab, Abbas Rahimi Froushani, Arash Rashidian and S Mahmoud Ghazi Tabatabaei,2012;Zarei et al. BMC Health Services Research 2012, 12:31 http://www.biomedcentral.com/ 1472-6963/12/31.

87

CoskunBakar and H. Seval Akgun(2008)130 applied SERVQUAL scale was

implemented into routine use at the Baskent University Hospitals Network in Baskent,

Turkey. The study consisted of 550 randomly chosen patients who presented to any

member hospital in that network during January and February 2006 and received

treatment as inpatients or outpatients at those healthcare facilities. The SERVQUAL scale

was utilised to evaluate hospital services. The study extracted the perceived scores of the

patients were higher than expected for an ordinary hospital but lower than expected for a

high-quality hospital. The highest difference between the perceived service score and the

expected service score was found at the Alanya Application and Research Center in

Alanya, Turkey. The paper demonstrated the use of the SERVQUAL scale in measuring

the functional quality of the hospitals assessed.

Lam (1997)131examined the validity, reliability and predictive validity of

SERVQUAL and analyzed its applicability to the health sector in Hong Kong. The

study result proved that SERVQUAL is a reliable model to measure health care

service quality. However, factor analysis on five dimensions indicated that the scale

could be treated as one-dimensional for the results identified one dominating factor

representing expectations and perceptions.

Jaboun and Chaker(2003)132 conducted a comparative study on public and private

hospitals at UAE. Their research result revealed that there was a significant

differences between private and public hospitals in terms of overall service quality in

empathy, tangibles, reliability and administrative responsiveness. They conducted a

comparative analysis between private and public hospitals and pointed out that public

hospitals were perceived to be better than the private hospitals as far as service quality

is concerned. Kilbourneet.al. (2004)133, in his study, proved that SERVQUAL is

capable of capturing even slight quality indicators in a multidimensional way, namely,

tangibles, responsiveness, reliability and empathy as well as overall service quality.

130Coskun Bakar and H. Seval Akgun( 2008), ‘The role of expectations in patient assessments of

hospital care An example from a university hospital network, Turkey’; International Journal of Health Care Quality AssuranceVol. 21 No. 4, 2008pp. 343-355.

131Lam SSK (1997). SERVQUAL: A tool for measuring patient’s opinions of hospital service quality in Hong Kong. Total Qual. Manage., 8(4):145-52.

132Jabnoun N, Chaker M (2003). Comparing the quality of private and public hospitals. Managing Serv. Qual., 13(4): 290-299.

133Kilbourne WE, Duffy JA, Duffy M, Giarchi G (2004). The applicability of SERVQUAL in cross-national measurements of health-care quality. J. Serv. Mark., 18(7): 524-33.

88

Qin et.al.(2009)134considered the perceived quality as one of the antecedents of

patient satisfaction and compared perceived quality with the expected service quality

on the basis of SERVQUAL model to measure the satisfaction level of a patient

regarding waiting time in a hospital. They considered a hypothesis that the service

quality directly and positively influences patient satisfaction. They were also able to

prove that the service quality is one of the antecedents of patient satisfaction.

Lim and Tang(2000)135measured satisfaction of 252 patients in hospitals of

Singapore by applying modified version of SERVQUAL and found that the hospital

needed improvements across all six dimensions viz. tangibles, reliability, assurance,

responsiveness, empathy, accessibility and affordability.

Wong (2002)136 pointed out that three dimensions viz. responsiveness, assurance and

empathy of SERVQUAL model were more important factors than other two

dimensions affecting overall patient satisfaction.

Karassavidouet.al. (2007)137applied SERVQUAL model to measure a service quality

on three dimensions viz. a) human aspects, b) physical environment and infrastructure

of the care unit and c) access. They applied a modified version of SERVQUAL model

where demographic features of patients (age, gender, education and income) have

been taken into account.

Mahmood Nekoei-Moghadam and Mohammadreza Amiresmaili (2011)138

assessed hospital service quality. The present descriptive study was carried out

through a cross-sectional method in 2008. The participants of this study were patients

who had been referred to Kerman University of Medical Sciences hospitals. The

sample comprised 385 patients, the data were collected by SERVQUAL as a standard 134Qin H., Prybutok V.r.( 2009), Perceived Service Quality in the Urgent Care Industry, 548-556:

www.swdsi.org/swdsi2009/Papers/9N03.pdf. 135Lim, P. and Tang, N. (2000), A study of patient’s expectations and satisfaction in Singapore

hospitals’, International Journal of Health Care Quality Assurance 13 (7), 290-299. 136Wong J (2002). Service quality measurement in a medical imaging department. Int. J. Health Care

Qual. Assur. 15(2): 206-12. 137Karassavidou E., Glaveli N., Papadopoulos C.T. (2008), Health Care Quality in Greek NHS

Hospitals: No one knows better than patients, 11th QMOD Conference. Quality Management and Organizational Development Attaining Sustainability From Organizational Excellence to Sustainable Excellence, 20–22 August, 2008 in Helsingborg, Sweden www.ep.liu.se/ecp/033/039/ecp0803339.pdf.

138Mahmood Nekoei-Moghadam and Mohammadreza Amiresmaili (2011),titled “Hospital services quality assessment” International Journal of Health Care Quality Assurance Vol. 24 No. 1, 2011 pp. 57-66.

89

questionnaire, and data analysis was carried out on 385 completed questionnaires. In

all five dimensions of quality, a gap was observed between patients’ perceptions and

expectations as follows: Assurance: 21.28, Empathy: 21.36, Responsiveness: 21.80,

Tangibles: 21.86 and Reliability: 21.69. A paired T-test showed that the differences

between quality perceptions and expectations are significant (p value , 0.05). Based

on the findings of this research, the hospitals in the study did not meet the

expectations of patients and were unable to provide health care services according to

patients’ expectations. Hence rearranging the service delivery and deploying better

facilities and equipment in order to decrease the gap between patients’ perceptions

and expectations may be helpful.

Despite its critics, SERVQUAL has been widely used in many service industries

including hotels, travel, higher education, real states, accountancy, architecture,

construction services, hospitals, dentistry, call - centers (Foster, 2001)139. Indeed, in

health care most studies that explore quality apply SERVQUAL. The focus of these

studies varies and refers to: identification of the dimensions of service quality and

assessment of the level of quality provided by hospitals or across a number of service

categories provided by the hospital (Mostafa, 2006)140.

2.6 Conclusion:

The main objective of any healthcare system is to facilitate the achievement of

optimal level of health to the community through the delivery of services of

appropriate quality and quantity. The level of competition has increased in health care

sector. Patients’ satisfaction is emphasized highly in competitive market.

From the literature review on patients satisfaction, hospital management , hospital

governance, service quality and SERVQUAL in health care industry, it is observed

majority of the authors studied only a particular one hospital i.e. multi-specialty

hospital or special hospital. Few of them have done comparative analysis of private

and public hospital. In some studies only service quality is studied and hence the

scope of these studies becomes limited. In this research factors influencing choice of 139 Foster, .T. Jr (2001), Managing Quality : An Integrative Approach, Prentice - Hall, Upper Saddle

River, NJ, pp. 223-44. 140Mostafa, M.M. (2006), An empirical study of patients; expectations and satisfaction in Egyptian

Hospitals", International Journal of Health Care Quality Assurance, Vol. 18, No. 7, pp. 516-32.

90

hospital and service quality is measured. And also satisfaction level and patients’

loyalty also studied. In addition to that analysis on Service Quality model given by

Parasuraman et al. is also included which highlights important t dimensions of

services which the private Hospitals need to address.

Also many studies were reviewed based on Service Quality model given by

Parsuraman et al. The use of this model in Private Health care Industry in India is

very rare. Again the same model is not used for Private Health sector in the state of

Gujarat, Which again makes this study different from others.

From the literature review on Health care sector, topics studied by various authors are,

patients satisfaction, determining factors of satisfaction, health care management,

various aspects of hospital management, use of quality control techniques by hospitals

and its impact on performance, significance of quality control and use of Service

Quality model in health care sector. Hence , it can be observed that service quality

model has been successfully applied to hospitals services by various researchers.

In this thesis research is conducted to know service quality and patients satisfaction

in selected Private Hospitals of Gujarat.

91

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